Doctors afraid new fee will reduce customers … er, patients

October 30th, 2011 by Philip Brasor & Masako Tsubuku

At the end of September the Ministry of Health Labor and Welfare released figures for medical care expenditures in fiscal 2009. Based on national insurance records, Japanese people spent ¥36.67 trillion on medical care that year, a 3.4 percent increase over 2008. That boils down to ¥282,400 for each man, woman or child, which is a 3.6 percent increase over the previous year. Broken down demographically, patients between the ages of 65 and 74 accounted for 55.4 percent of money spent (¥19.94 trillion) and patients 75 and over 32.6 percent (¥11.73 trillion). Per capita, Japanese under 65 spent ¥163,000 for the year, those between 65 and 74 ¥687,000, and those 75 and older ¥855,800. In terms of sources of revenue, 48.6 percent (¥17.5 trillion) came from premiums for both the Kokumin Kenko Hoken (National Health Insurance) and the Kenko Hoken (Employees Health Insurance) systems; 37.5 percent (¥13. 49 trillion) came from national and local taxes; and the remaining 13.9 percent (¥4.99 trillion) came from patients’ pockets.

The kid stays in the picture: JMA ad against proposed ¥100 fee

These amounts were the highest since MHLW started keeping track. Japan’s Gross Domestic Product went down in 2009, but the portion of GDP accounted for by medical care, 7.6 percent, was higher than the previous year’s portion, which means that not only is more money from premiums being spent, but more people are paying out-of-pocket for medical care, since 10-30 percent of a doctor’s and pharmacist’s bill is paid for by the patient. This portion can be extremely large when hospitalization or special treatments are involved, and in many cases where patients’ expenses are exceedingly high (kogaku iryohi) the government will reimburse them depending on their individual incomes. The MHLW has decided that the current pay schedule for this excessive medical expense system is obsolete, and has restructured it to allow more income brackets and higher reimbursements. The problem is that as the population ages revenues from premiums are going down since people over a certain age pay less, even as they use more insurance. So where are they going to get the money to fund this new excessive medical expense system?

The provisional answer is something called the madoguchi futan (literally, “window burden”), a ¥100 fee that will be added to every doctor’s visit and paid by the patient. The Japan Medical Association has roundly condemned this fee, saying that it penalizes older people and others on fixed incomes, effectively widening the gap between rich and poor. In the long run, it will discourage lower income people from seeking medical help.

That, in fact, seems to be the intent. One of the more problematic aspects of Japan’s national health insurance program is that people have no compunction about going to the doctor for minor or insignificant problems, like colds. This is especially an issue when it comes to the elderly, who pay less out-of-pocket than younger people. To them, medical care is practically free, so they go as often as possible, and thus place a huge strain on the national health insurance system. According to the Asahi Shimbun, the MHLW estimates that it needs ¥410 billion a year to pay for this new excessive medical expenses system. The ¥100 fee for every doctor’s visit will raise about ¥210 billion, but more importantly, the MHLW projects that it will act as a discouragement and thus reduce doctor’s visits to the tune of ¥200 billion. Some other newspapers, including the Mainichi, have downplayed this aspect and said that the money for the new system could be paid for completely by the ¥100 fee — but not for very long.

Nevertheless, the idea is still just a proposal, and certain members of both the ruling and opposition parties have said they are against it. The JMA has pointed out that when the administration of Junichiro Koizumi hiked the out-of-pocket portion for Kenko Hoken members under 65 to 30 percent, the government also promised it wouldn’t increase the burden again, and this ¥100 fee breaks that pledge. Still, if the JMA is worried about the hardship for the elderly, the ¥100 fee is certainly less burdensome than the MHLW’s proposal for hiking the out-of-pocket payments for over-74 patients from 10 to 20 percent, though they haven’t talked about it for a while. As it stands, 50 percent of the funds used for paying the medical bills of over-75 patients come from tax revenues, and 40 percent comes from the health insurance premiums of younger people. You can see how much you yourself pay toward this special insurance on your yearly insurance bill under the category of koki koreisha, which means “late elderly,” or, more colloquially, “really old.”

Yen for Living is produced by Philip Brasor, a freelance writer-for-hire, and Masako Tsubuku, a freelance translator and interpreter. They are currently working together on a book about Japanese housing that will probably never be finished. In the meantime they have their own blog on the subject: Cat Foreheads & Rabbit Hutches. You can read more by Philip at philipbrasor.com.

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One Response

I do feel that people tend to abuse the system. I remember how astonished I was when Japanese co-workers advised me to go to the doctor for a slight cold … that would be unthinkable where I come from. I also remember my first sight of the local clinic’s crowded waiting room – I thought I’d accidentally walked into a nursing home, as I was literally the only person in the room under the age of 65.

The other day I got into the elevator of my apartment and encountered three elderly ladies on their way to the local hospital. They looked very cheerful and genki, and one of them mentioned a fourth lady who “can’t join us today, she has a cold.” So it’s not just an urban legend after all, they really do have conversations like that!